CD40 Ligand Deficiency Presenting As Unresponsive Neutropenia Arch Dis Child: First Published As 10.1136/Adc.74.5.458 on 1 May 1996

Home , Dysgammaglobulinemia, Hyper IgM syndrome, Neutropenia

458 Archives ofDisease in Childhood 1996; 74: 458-459

CD40 ligand deficiency presenting as unresponsive neutropenia Arch Dis Child: first published as 10.1136/adc.74.5.458 on 1 May 1996. Downloaded from

Francis J Andrews, Faye Katz, Alison Jones, Susie Smith, Adam Finn

Abstract subsequently continued to fluctuate unpre- A male child presented with recurrent res- dictably between 0 and 1-7, and the daily dose piratory infections, otitis media, and oral was progressively increased to 24 ,uglkg. The ulceration and was found to be neutro- patient suffered two further attacks of otitis penic. Investigations showed hypogamma- media. Culture of accompanying aural dis- globulinaemia with normal serum IgM and charges yielded Spneumoniae and H influenzae. a novel deletion in the gene for CD40 ligand Assays of immunoglobulin isotypes at 24 on his X chromosome. Intravenous gam- months of age showed (g/l) IgG 2-1, IgA <0-2, maglobulin did not lead to resolution ofhis IgM 16, IgG, 157, IgG2 026, IgG3 0.1, and neutropenia; G-CSF was also necessary. IgG4 <0-02; IgE was 2 iu/l. With the exception (Arch Dis Child 1996; 74: 458-459) of IgE, IgM, IgG3, and IgG4, these values are abnormally low. Circulating numbers of CD3, Keywords: hyper IgM syndrome, neutropenia, CD40 ligand deficiency. CD4, CD8, CD16, and CD19 positive lymphocytes were normal. No anti-neutrophil antibodies were detected and protein electro- phoresis of serum showed no abnormalities. The hyper IgM syndrome is characterised by Suboptimal responses to previous vaccination low plasma concentrations of IgG, IgA, and against polio, measles, mumps, and rubella IgE associated with normal or increased levels were demonstrated, but circulating isohaemag- of IgM. It is usually an X linked primary glutinins (anti-A) were detectable. He com- immunodeficiency caused by a mutation in the menced regular prophylactic cotrimoxazole, gene for the T cell surface protein CD40 but had a further attack of otitis media. He also ligand' which is involved in T cell interaction developed primary varicella zoster infection; he with B cells and the induction of isotype was treated with intravenous acyclovir and switching. The condition often presents in the zoster immunoglobulin and made an unevent- first year of life with recurrent respiratory tract ful recovery. infections and with opportunistic infection, On the basis ofthese data a possible diagnosis especially with P carinii. In vitro assays of of hyper-IgM syndrome was suggested and T cell number and proliferation are normal. regular treatment with intravenous gamma- http://adc.bmj.com/ Neutropenia is occasionally associated with the globulin (Sandoz) (04 g/kg every three weeks) syndrome but the reason for this is unclear. was instituted. Immunofluorescence staining Treatment with prophylactic cotrimoxazole of activated lymphocytes confirmed absence of and intravenous gammaglobulin prevents expression of CD40 ligand (figure, A and B). infections and is reported to alleviate the Genomic DNA from the affected boy was PCR- neutropenia. amplified using primers spanning all five exons

of the CD40 ligand gene and screened for on October 2, 2021 by guest. Protected copyright. mutations using single strand conformational Case report polymorphism analysis (SSCP). A band shift A male infant was born by uncomplicated was identified in exon 5 (figure, C), and on delivery at 42 weeks' gestation and remained subsequent sequencing was found to represent well until the age of 6 months. Thereafter he a three-nucleotide deletion (nucleotides 568- suffered from repeated upper respiratory tract 570), which results in loss of an isoleucine infections, otitis media, mouth ulceration, and residue at position 171 (data not shown). oral candida infection. There was no relevant Despite starting IVGG and continuing treat- family history. Investigations done at 20 ment with subcutaneous GCSF 24 ,uglkg/d his Department of Paediatrics, University months of age, revealed a haemoglobin (Hb) neutrophil count continued to fluctuate and of Sheffield, Children's concentration of 9-1 g/dl with an MCV of 62-4 was often undetectable. His subsequent course Hospital, Sheffield fl, an MCH of 20-4 pg, and a neutrophil count was complicated by two central venous line S10 2TH F J Andrews of 0-2X 109/1. Five subsequent neutrophil infections, frequent pyrexial illness, and oral A Finn counts were less than 0-4X109/l and a bone ulceration. Eventually an increased dose of marrow aspirate showed maturation arrest at GCSF, 33 ,ug/kg/d, resulted in a persistently Division of Cell and an count an Molecular Biology, the myelocyte stage with features of iron normal neutrophil and improved Institute of Child deficiency anaemia. A diagnosis of chronic clinical course. Health, London idiopathic neutropenia was made. At 21 WCIN IEH treatment F Katz months of age, with recombinant A Jones human granulocyte colony stimulating factor Discussion S Smith (GCSF, Roche) was started at a dose of The neutropenia that is seen in some cases Correspondence to: 10 jxg/kg once daily, given subcutaneously. of hyper IgM syndrome2 cannot easily be Dr Adam Finn. After treatment with G-CSF for one week, the explained in terms of what is currently known Accepted 29 December 1995 neutrophil count had risen to 2-5XI09/l but about the function of CD40 ligand but suggests CD40 ligand deficiency presenting as unresponsive neutropenia 459

(A) Flow cytometric A that it plays a role in early myeloid differentia- fluorescence histograms of Furthermore, the responsiveness ofthese Tcells (separated by 150 tion.3 positive selection using neutropenias to treatment varies markedly in sheep erythrocyte rosetting Background - FITC only reported cases between responding to IVGG and density gradient alonel 4 or responding to additional GCSF Arch Dis Child: first published as 10.1136/adc.74.5.458 on 1 May 1996. Downloaded from centrifugation) from theaniD antiCD40L(5c8)L ) patient, following overnight antiCD25(aTac) therapy.5 In another case, neutropenia was stimulation with phorbol resistant to GCSF and corrected only by bone myristate acetate and marrow transplantation.6 ionomycin, stained with saturating concentrations of This case report emphasises the importance either mouse monoclonal of considering the possibility of an underlying anti-CD40 ligand antibody defect of specific immunity in a child who (Sc8) or anti-CD25 antibody (aTac) or nofirst presents with recurrent infections and is found antibody, followed, after to be neutropenic. Heterogeneous mutations washes, byfluorescein in the CD40 ligand gene have been reported to conjugated polyclonal goat anti-mouse serum. (B) date. Ifthis mutation or closely associated ones Equivalent histogramsfrom are found in other cases of CD40 ligand a normal adult control deficiency with neutropenia, this could shed sample processed in 10 101*--- 102 10 l parallel. In both, effective Patient some light on the mechanism ofthe association T cell activation is B between the two. On the other hand, we have demonstrated by detectable 1W0 also observed neutropenia in association with a CD25 expression, but, in minority of boys with X linked agammaglobu- contrast to the control, the patient's cells show no linaemia which is due to mutations in a differ- CD40 ligand expression. ent gene coding for a B cell tyrosine kinase, so (C) SSCP analysis ofthe it may be that neutropenia occurs in occasional PCR product ofexon 5 of the CD40 ligand gene, hypogammaglobulinaemic patients by a mech- digested wtth BsoF Ifor anism not directly due to the primary gene patient (track 1) and defect. control (track 2) samples. Background - FITC only The band shift in the single antiCD40L(5c8) We thank Drs B Paul and L Williams for referring this patient. strandedproducts are SS's work is supported by the MRC. indicated by closed arrows antiCD25(aTac) above compared to the 1 Korthauer U, GrafD, Mages HW, et al. Defective expression normalproducts, indicated of T-cell CD40 ligand causes X-linked immunodeficiency by open arrows below. with hyper-IgM. Nature 1993; 361: 539-41. 2 Banatvala N, Davies J, Kanariou M, Strobel S, Levinsky R, Morgan G. Hypogammaglobulinaemia associated with normal or increased IgM (the hyper IgM syndrome): a case 1 op lo0 102 103 104 series review. Arch Dis Child 1994; 71: 150-2. 3 Banchereau J, Bazan F, Blanchard D, et al. The CD40 anti- Control gen and its ligand. Annu Rev Immunol 1994; 12: 881-922. 4 Rieger CH, Moohr JW, Rothberg RM. Correction of neutropenia associated with dysgammaglobulinemia. Pediatrics 1974; 54: 508-11.

C 5 Wang WC, Cordoba J, Infante AJ, Conley ME. Successful http://adc.bmj.com/ treatment of neutropenia in the hyper-immunoglobulin M syndrome with granulocyte colony-stimulating factor. Am JPediatrHematol Oncol 1994; 16: 160-3. 6 Fasth A. Bone marrow transplantation for hyper-IgM syndrome. Immunodeficiency 1993; 4: 323.